Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan

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Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 23

by Ronald Glasser M. D.


  Stoner had also expected that distance would not be a big problem in the jungles of Southeast Asia. And for the most part he was right. But those shortcomings of the M-16 became obvious during the First Iraq War. The war was won quickly but, out in the open reaches of desert and long sight lines of central Iraq, the majority of engagements were at distances not experienced since the trench warfare of World War I.

  The M-16 needed greater reach. The military tightened the twists within the barrel and redesigned the bullet up from 55 to a weight of 62 grains. While making the cartridge more powerful, the military added a steel tip to the round, making the bullet lighter in the front and forcing the bullet to be intrinsically unstable so that it would wobble as it was spinning faster and reaching out to longer distances.

  But despite the readjustment, the give and take of physics goes to work. The now heavier bullet had a slower exit velocity, losing significant terminal energy the longer out it reached. The now rapidly spinning bullet didn’t always tumble as expected. In short, many of the hits from the newly designed M-16 round, while reaching further out, resulted in a small hole in, as well as a small hole out, leading to little, if any, internal damage other than along the track of the bullet. If the round did not hit a vital organ, break a bone, or cut a major artery, the person hit simply kept moving.

  The government and the Pentagon never acknowledged the problem or the danger to our troops. In the early 1990s, the standard M-16 was reincarnated into the M-4 weapon system. The M-4 is similar to an earlier compact model M-16 and still fires the 5.56 round. But it is a more convenient weapon than the full-sized M-16 to carry in cramped areas like tanks, trucks, Humvees, and Armored Personnel Carriers, while its smaller size makes it easier to use in the buildings, narrow streets, and alleyways of urban centers. But both the compact M-16 and the M-4 have a decidedly shorter barrel than the full sized M-16 and that shorter barrel means less initial exit velocity, and even less kinetic energy for the 2.23 cartridge.

  Once again, physics plays its own nasty game. The shorter barrel has the consequence of slowing the exit speed of the bullet. The speed of a bullet increases as the bullet is pushed forward down the barrel by the expanding gases of the cartridge. Shorten a barrel for any reason and the amount of time the bullet is exposed to the expanding gases decreases, and the slower the bullet is moving as it exits the rifle, the lower the terminal velocity.

  Surprisingly, this sacrifice in exit velocity and the decrease in terminal ballistics, in exchange for the ease of handling of a weapon, are considered to be a worthwhile compromise. There is no doubt that the M-4 is an adequate weapon for troops under close conditions. But for shooting at enemy forces at middle and long distances or trying to fire at insurgents behind rocks and stone walls, most troops would rather have a 30-caliber round and a rifle with a longer barrel.

  Those who have made the fight in Iraq and Afghanistan understand that we have come full circle and that, in order to win these wars, at least down at the platoon and company-sized firefights, we have to go back to World War I and have a weapon in our arsenal that can be aimed and is both accurate and deadly out at long distances.

  The refusal to do this is undoubtedly due to sheer exhaustion. We are still reeling from how we got into all of this and how unprepared we were for what actually happened. The result is an Army and Marine Corps that is stretched too thin.

  Secretary of Defense Robert Gates, who will retire this year, and so can speak openly, recently expressed both the country’s and the military’s confusion, “This war will always be clouded by how it began.” And so these wars remain clouded not only as to how they should end but how they should be fought.

  Bob Woodward’s newest book, Obama’s War, describes Vice President Biden’s trip to Iraq and Afghanistan right after the 2008 presidential election. As Woodward describes the three-day trip, the Vice President, in his usual loquacious way, asked everyone he met, particularly the commanders in the field, how they thought things were going and how they thought things could be improved. He became distressed as he gradually realized that the commanders making the fight had no real idea why they were there, what the exit strategy was, and more importantly, what victory or even defeat would actually mean. Woodward makes clear that Biden is eighteen years older than the President and adds to the description of the trip that the majority of commanders viewed the Karzai government as corrupt and that Biden, remembering Vietnam, could not help but think that this was Vietnam all over again.

  The military’s effort in all this has been directed to trying to get its mission right amid the confusion of changing goals such as counter-insurgency, counter-terrorism, nation-building, democracy or federalism, staying as long as necessary, or leaving by a certain date.

  All this shifting about has made changing a major weapon system given to our 4.5 million regular duty military, national guard, and reserve personnel an enormous task. It could only be considered a further kind of tinkering to a military trying not to look foolish and actually trying to survive. The armament industry, with its lobbyists and consulting retired generals and colonels, are all too willing to go before Congress to testify that our weapons are the best in the world, while explaining that they are effective if used correctly and within approved guidelines. And those on active duty who are running the roads and working in the Afghan mountains do not have the time, the energy, or the clout to make that kind of fight to make things right.

  But for those in the business of saving lives and trying to make people whole again it is not only necessary, but an absolute requirement, to tinker down at the very tip of the spear.

  Afghanistan may not yet be Vietnam, but neither is the new Taliban the old Taliban. Those now fighting in Afghanistan are no longer disorganized insurgents trying their luck at playing soldier. The most recent Taliban attacks are coordinated and militarily sophisticated. Our own military responses have to be more immediate, more formidable and more deadly. Today there is even more of a value in engaging the enemy at a distance as well as being able to kill them at close quarters. And for that—we need a larger bullet.

  Upgrading our M-4s would mean little more than changing the barrels, as well as altering the receivers to accept a larger round. It would be expensive. But so are the orthopedic wards at Walter Reed, the Rehab Center at Brooks Army Hospital in Texas, and the Poly-trauma Units at the VA hospitals across the country.

  But there is a more immediate and decidedly cheaper answer to the whole issue of a better weapon for the 50,000 troops we will be leaving behind in Iraq and the 150,000 troops in Afghanistan. The military will have to unwind its history of the last half dozen decades and ignore that “Spray and Pray’” approach to the use of individual weapons, and go back to having our troops look at what they want to shoot and then reach out and hit those who have been targeted.

  William Langewiesche, international correspondent for Vanity Fair, in his article “The Distant Executioner,” published in February 2010, tells the story of what is happening today in our military regarding its weapon systems and what must happen in the future. Langewiesche would hardly view his article as an essay on preventive medicine but that is precisely what it is. There is a great deal more Patton than Hippocrates in what today’s military physicians are forced to deal with and have to face on a daily basis. But then again, Patton knew a great deal more about war than Hippocrates.

  According to Langewiesche, there are fewer than 2,000 fully-trained snipers in the Army and National Guard, fewer than 800 in the Marines, and a few dozen in the Air Force and Navy. Yet, when he interviewed those officers making the fight in Iraq and now in Afghanistan, it was clear that these specialists are considered to be valuable assets, but still too scarce to be assigned to regular front line units.

  The solution Langewiesche presents is basically to train more front line troops to act as “snipers” and give them the sniper’s favorite bolt-action Remington rifle using a large 30-caliber round, and then add those who become qual
ified to the inventory of every squad, or, at the very minimum, to every platoon in the military that is or will be sent to Iraq or Afghanistan. As the author points out, a new Military Occupational Specialty classification or MOS of “Marksman,” to go along with the other military specialties from Radio Operator to Medic, would ignore the atmospherics that go with the current MOS of “Sniper.”

  What is implicit in the article is that the addition of a single marksman to every operational unit gives the necessary reach our troops need for both personal and unit security. The added implication to that important factor is that crucial dimension, absolutely critical to winning the hearts and minds of those in a war zone, of not shooting what shouldn’t be shot and not killing who shouldn’t be killed.

  There is an irony in all of this. We have a high-technology army with ever-increasing, computerized, real-time battlefield situational awareness, unmanned drone flights that fire on-demand hell-fire missiles guided by an operational command center in Fort Bliss, Texas, cell phone intercepts, and high-resolution satellite imagery used to pin-point potential military targets. In the midst of all this, a single marksman using a high-power scope and firing a single heavy .308-caliber bullet from a bolt-action Remington 700 rifle may actually be both our newest, as well as our best, secret weapon.

  We may have come full circle, though the physician’s role in all of this hasn’t changed over the decades, much less over the centuries. It is what it has always been, to save those who can be saved and try to fix those who can be fixed. But it has also been to bear witness. Medicine has never offered immortality, but it has offered relief from suffering, as well as an understanding of grief and loss. But at its best, medicine has offered prevention and concern for each individual patient. That too is part of the Hippocratic Oath.

  It is not the least bit ironic, nor a stretch, but with prevention and individual concern in mind, the addition of marksmen to every unit in Iraq and Afghanistan, along with increasing the caliber of the bullets used by all the troops, may well be the best medicine for those we send to make our fights—other than never having sent them in the first place.

  20.

  “IS MY JUNK ALL TOGETHER?”

  Everybody was taken aback by the frequency of these injuries: the double amputations, the injuries to the penis and testicles. Nothing like this has been seen before … unbeliveable.

  —Dr. John Holcomb, retired Army Colonel

  Since the surge in Afghanistan of 30,000 new troops in 2010 along with the new emphasis on counterinsurgency—the winning of hearts and minds through foot patrols in order to get to know the villagers—rather than the counterterrorism strategy of simply killing the bad guys, the surgeons caring for our wounded are beginning to speak of a new kind of “signature wound”. New tactics and new strategies always lead to new kinds of injuries.

  These wounds have been seen before but never in such numbers that they can no longer be ignored or explained away as just bad luck. As one of the military trauma surgeons recently offered, “I’ve seen these types of injuries before. What I haven’t seen is them coming in over and over and over again.”

  The new signature wound is a composite injury and usually the result of a soldier stepping on a buried land mine. It is two legs blown off at the knee or higher with severe damage to the genitals, colon, rectum, and bladder. Multiple limb amputations have always been a part of the fight in Iraq and Afghanistan, but these genital wounds resulting in the loss one or both testicles while requiring colostomies as well as bladder reconstructions all taken together in the same patients is something new. But put your troops on the ground as foot patrols walking into and around villages or across farm compounds and these are the wounds you get. In addition, a number of these patients require “hip disarticulations”—the removal of the entire thigh bone, which makes the use of a future prosthesis at best problematical if not actually impossible.

  The surgeons at Landstuhl Regional Medical Center in Germany where virtually every severely wounded soldier and marine is sent on their way back to the States must have felt much like Ambroise Paré in the 16th Century when Paré was forced to deal with the shattering injuries from gunshot wounds.

  The problem was the body armor. The armor clearly reduced fatalities and the triangular flap on the lower part of the armor protects the groin from projectiles coming from the front, but does not protect the legs nor the areas between the legs, specifically the genitals, the bladder, and rectum from any upward moving blasts or projectiles.

  The army has been reluctant to acknowledge these new types of wounds through some fear of giving the enemy information and potential insights into making their IEDs and other weapons even more effective. But the troops know. With the numbers of wounded losing one or both testicles on the rise, those who have been deployed are telling those who are to be deployed to store some of their sperm at home before they leave the States for the mountains and plains of Afghanistan.

  This is not a foolish concern. An intensive care nurse at Landstuhl explained the new reality. Those most severely injured arrive at Landstuhl unconscious or heavily sedated, usually regaining some consciousness within two to three days. “The first thing we let them know is they are in Germany. We tell them that they are hurt but okay.” The first question the wounded then ask, even before they check for their arms and legs—“Is my junk all together?”

  The soldiers and marines know at least one of the real outcomes of a counter-insurgency that relies on foot patrols in a landscape set up for war. There is currently nothing in the medical literature about the long-term care, the effectiveness of the different male hormone-replacement therapies, quality of life issues, or the psychological adjustments for injuries that cause the destruction of or damage to the male sexual organs. But someone is going to have to figure all this out and figure it out quickly because these kinds of wounds are not going away and will only increase in number the longer we stay in those mountains and valleys.

  21.

  CHRONICLES/REDUXING VIETNAM

  This summer over 2,300 years ago, Alexander the Great, after conquering most of the known world, barely makes it out of Afghanistan into India through the Hindu Kush with less than a third of his army by marrying the daughter of the Northern Afghan Chieftain. When you look at a map of the conquests of Genghis Kahn in the Thirteenth Century—the lands conquered in blues and greens—everything from China, the Russian Steppes through the Middle East, and half of Europe is in color except a tiny white circular dot below the Himalayan mountains that represents today’s Afghanistan.

  In 1842, during the Second Anglo-Afghan War, all of the 20,000 British troops sent there in what Kipling called “The Great Game of Politics” were killed in the mountain passes above Kabul with only one officer, a physician, making it out of those mountains.

  The Soviet Union invaded Afghanistan on Christmas Day, 1979 and left nine years later in February of 1989. The Russians had ended up with over 250,000 troops in Afghanistan with absolutely no rules of engagement. They could kill anyone and destroy any village they chose—and they did.

  Over that nine-year period, a million Afghans were killed and another 3 million became refugees, and yet, like every other invading army, the Russians eventually had to leave. Afghanistan is a tough place to fight and even a tougher place to win. The landscape is set up for war.

  In recently released transcripts of Politburo meetings in the winter of 1986, three years before the Soviet leaders pulled the Russian Army out of Afghanistan, Sergei Akhromeyev, commanding the Soviet Armed Forces, explained the problems his soldiers were facing fighting in the hills around Kabul, as well as in the Kandahar and Helmand Provinces now occupied and patrolled by U.S. troops.

  “Our soldiers are not to blame,” Marshall Akhromeyev made clear. “They’ve fought incredibly bravely in adverse conditions. There is no piece of land in Afghanistan that has not been occupied by one of our soldiers at some time or another. Nevertheless, much territory stays in the hands
of the terrorists.”

  “We control the provincial centers, but we cannot maintain political control over the territory we seize. To occupy towns and villages temporarily has little value in such a vast land where the insurgents can just disappear into the hills. … 99 percent of the battles and skirmishes that we fought in Afghanistan were won by our side. The problem is that the next morning there is the same situation, as if there had been no battle. The terrorists are again in the village where they were—or we thought they were—destroyed a day or so before.”

  Marshall Akhromeyev went on to request extra troops and equipment.

  “Without them, without a lot more men, this war will continue for a very, very long time.”

  Before the invasion, the Chief of the Soviet Defense Staff, Marshal Nikolai Ogarkov, had raised doubts about the invasion. He had told Dmitri Ustinov—then defense minister —“that the experience of the British and Czarist armies in the Nineteenth Century should encourage caution.”

  A review of history should have cautioned anyone thinking of invading those mountains or those plains of Afghanistan. Why it didn’t cause us to hesitate remains an abiding mystery. It may simply be Arthur Schlesinger’s warning about those four most dangerous words in the English language, “This Time It’s Different,” again being ignored.

  The Russians continued their war for three more years before they finally withdrew from Afghanistan and went home. In fact, before the withdrawal in 1989, there had been a military recommendation for a “surge,” Soviet style.

  The equivalent of the head of the Russian Joint Chiefs of Staff had suggested sending in the whole of the Russian Army. The transcripts reveal that Mikhail Gorbachev, who had become the Russian leader in March of 1985 and had privately begun calling Afghanistan “our bleeding wound,” would have none of it. There was to be no surge. Gorbachev eventually opted to pull out the troops and go home. At the same time that Gorbachev was trying to decide how best to deal with his disastrous war, Anatoly Chernyayev, his chief foreign policy aide, was writing in his own personal diary that Afghanistan had become “Our Vietnam. But worse.”

 

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